NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code

NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code

Michael:

With furthering questioning of Mom you find that Michael has not wanted to play outdoors. He says he can’t keep up with the other kids in gym class. He says he gets dizzy sometimes too.

PE

VS

Height: 48 inches weight 78 pounds BP 110/70 T 98.2 P 65 R 16.

General

Caucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes.

HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation.Throat: Oropharynx dry, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. MS: reflexes WNL. Gait steady.

Labs

CBC:WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5

Fasting glucose 136 mg/dL

TSH: 2.6 mIU/L free T4 15 pmol/L

Mary

With further questioning Mary reports feeling more short of breath when doing regular activities, finding it harder to keep up with the kids. Her appetite is less and she is finding it harder to concentrate. At times she feels lightheaded. She says her periods have been heavier since she had her twins but there has been no increased flow or irregular bleeding. LMP was one week ago and lasted four days.

VS

Height: 64 inches, weight 155 pounds BP 115/86 T 99.0 P 62 R 16

General

Caucasian female, appears stated age. Alert, oriented and cooperative. Gait normal. Skin: Skin warm, dry and intact, color is pale pink, no cyanosis or pallor. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: .Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Slight periorbital edema noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Tongue noted to have teeth indentations around the edges. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with bowel sounds noted in all four quadrants. No organomegaly noted.

Labs:

CBC:WBC 8 Hgb 10.1 Hct33 RBC 3.2 MCV 74 MCHC 27.8 RDW 18.1

TSH:6.5mIU/L antithyroid antibodies:1:1,800

Discussion part two:

Summarize the history and results of the physical exam for each patient in a SOAP note for each case study patient. List the primary diagnosis with ICD 10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an EBP citation. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.

NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code

Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

Your next room has 2 charts in the box. It is the mother and son of a family that you know well. You review the chart before entering the room to familiarize yourself with these patients. Both present today with complaints of fatigue.

When you enter the room you see a woman who appears her stated age sitting in the chair and a boy who looks about 10 years old sitting on the exam table. You introduce yourself as you always do and ask what brings them both in to see you today.

Mary states, “We have both been usually tired. I have noticed Michael has not been himself for a few weeks, maybe more. He had a cold like rest of the family had but he just seemed to have it worse. He seems to have no energy, is never hungry anymore and has lost some weight. He seems to be always thirsty and he actually wet the bed last week. He has been sleeping more but I thought maybe he was growing”

Mary states “I have not felt like I had any energy since I got that cold about 6 weeks ago. I am always tired and my eyes are always puffy. I know I have a really busy life but I am more tired than usual. I come home from work and I just want to go to bed. I’m cold all the time and I seem to be having more headaches too”

Michael:

PMH

Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin

Social History

Good student, oldest of four children. Lives with parents, grandparents and siblings. Have 2 dogs and a cat.

Family History

Parents and siblings are in good health,MGM: HTN and hyperlipidemia. MGF: HTN and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia

Mary

PMH

Reports overall good health. Denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.

Social

Married, high school graduate, works full time at a local business in the ordering department. Lives with husband, children and parents. Husband and father both smoke but not in the house.

Family

Mary has 2 siblings who are in good health.&; Mother has HTN and hyperlipidemia. Father has HTN and hyperlipidemia.

Discussion Part One:

  • What further questions do you have forMichael or his mother at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
  • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
  • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
  • What further questions do you have forMary at this visit?&; Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
  • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
  • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
  • NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code
  • Setting: large urban city

    Family practice clinic which employs physicians and nurse practitioners.

    Today is another busy in your family practice clinic. You note your next visit is a “2fer”. This means you have two patients to see in this visit. You ask your medical assistant to tell you why they are here. Your medical assistant tells you the patients are daughter and father. The daughter has burning with urination and the dad came along for the visit because he has some back pain. You review the chart before entering the room to familiarize yourself with these patients.

    When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. She is sitting in the chair. The man is well groomed, appears to be about 70 years old, and is sitting on the exam table leaning forward. You introduce yourself as you always do and ask what brings them to the clinic today.

    Mary

    HPI

    Reports burning with urination and feeling very itchy and uncomfortable in that area.

    PMH

    Age 44. No chronic illness or injuries. Recently treated for strep throat with a 10 day course of penicillin. Completed 1 day ago. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.

    Social history

    Mary is married with four children ages 4-9. She works full time. Mary’s parents Katie and John also live in the home. Both are retired and help with childcare and household needs since both parents work full time. Her husband and father both smoke but not in the house.

    Family history

    Mary has 2 siblings who are in good health. Mother has a history of HTN, hyperlipidemia and osteopenia. Father has HTN and hyperlipidemia. They share their home with 2 dogs and a cat.

    John

    HPI

    States he has had some back pain for three days that has not gotten better. He has taken Tylenol three times per day and though it takes the edge off it has not helped much and the pain is still there.

    PMH

    Age 75. Has HTN and hyperlipidemia. No previous injuries. No hospitalizations or surgeries. Takes Lipitor 40 mg daily and Lisinopril/HCTZ 20, 12.5 daily. Allergic to Bactrim. Sleeps 6-7 hours a night.

    Social

    Born in Ireland, has lived in America for 45 years. Lives with his wife in his daughter and son in laws home. Retired carpenter. Helps with the kids by taking them to school and after school activities. Enjoys gardening and fixing things around the house. Drinks ETOH on the weekends and smokes 1 pack a day. Denies other drug use.

    FMH

    Parents lived until their 80’s. Has 13 siblings, most are alive. One brother died suddenly of a heart attack age 45 and lost a sister at age 4 to consumption. No family health problems except for high blood pressure when they get older.

    Discussion part one:

    • What further questions do you have forMary at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
    • What further questions do you have forJohn at this visit? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?

    Week 5: Discussion Part Two

    77 unread replies.3434 replies.Before proceeding with some delicate questioning about Mary’s condition you ask if she is comfortable discussing her condition in front of her father. Mary states she does not mind and continues the interview.

    Mary

    Interview: Her last menstrual period (LMP) was two weeks ago.

    No reports of headache or vision changes. No fever, chills, nausea or vomiting. No ear pain. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Reports vulvar itching and burning with urination x 2 days. No reports of incontinence. No back pain. Feels “not right”. Is sexually active, denies dyspareunia. Has tried drinking more water, Monistat cream and cranberry pills. Nothing has really seemed to work, nothing makes it feel better.

    VS

    Height: 64 inches, weight 149 pounds BP 128/72, T 101.2, P 100, regular and R 14.

    Focused exam

    General: Alert, oriented and cooperative. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen soft, slight tenderness noted over suprapubic region, bowel sounds auscultated in all four quadrants fields. No organomegaly noted. No CVAT.

    Labs: Urine dip: + leukocyte esterase. Small. Positive nitrites. Small blood. Trace protein, pH 7.0 specific gravity 1.020, negative ketones, and negative glucose. Urine HCG negative.

    Based on reports of vulvar itching you perform a pelvic exam. Vulva with erythema and excoriation noted, most likely due to scratching. Urethra without swelling or discharge noted. Bartholin glands nontender, no enlargement bilaterally. Thick white curdy discharge noted in vagina, vaginal walls, erythema noted. Cervix pink, midline, smooth without excoriation, parous os, secretions cloudy, thick, stringy without odor. Bimanual exam: no pain with cervical palpation, uterus and ovaries not enlarged.

    Wet prep: negative clue cells, positive hyphae. pH 4.0 Whiff negative

    John

    No fever, chills, nausea or vomiting. No ear pain. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Stated he has not had this back pain problem in the past, he does not remember an injury. It is difficult to stand up straight. Pain is in left lower back, no radiation. Pain is worse with standing and bending over. Pain is less when sitting. No reports of trouble with his bladder or bowels.

    VS

    Height 5 feet 7 inches weight 195 pounds T 98.4, BP 150/84, P 90, R 20.

    Focused exam

    General: Alert, oriented and cooperative. Cardiopulmonary: Heart S1 and S2 noted, RRR, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Back: skin intact, warm and dry, no petecchiae, lesions or masses noted. Patellar reflexes brisk bilaterally. Normal spinal curvature. Tenderness noted upon palpation of left side lateral to lumbar spine. Straight leg raise is negative bilaterally. ROM: Unable to touch his toes, flexion is about 45 degrees. Gait is slow and appears unable to stand up straight, he is leaning forward slightly when walking.

    Discussion Part Two

    Summarize the history and results of the physical exam for each patient in a separate SOAP note for each case study patient.

    Calculate the BMI for each patient.

    List the primary diagnosis with ICD10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.

    Week 4: Discussion Part One

    77 unread replies.3030 replies.

    Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

    Your next patient is a work in for abdominal pain.

    When reviewing the chart you see that this is Patrick Smith, age 42. You met him last month when he brought his mother-in-law in for a sick visit. You remember because you treated him as well for a skin condition.

    You enter the room and introduce yourself again to Patrick. He is not the jovial man you met last visit; he appears to be uncomfortable as he reaches forward to shake your outstretched hand.

    Patrick says he is in a lot of pain. He thought it would go away but it is lasting and seems to be getting worse. He is also nauseous. He doesn’t think it is anything that he ate and no one at home has had the stomach flu. It is getting worse as he has been sitting in the office. He cannot find a comfortable position to sit.

    HPI

    Woke up at 5 a. m. started out as pain on one side of his back. He thought he pulled a muscle. Now pain is spreading to his stomach and is getting worse. The pain sometimes shoots down into his groin. He feels nauseous. He seems to be going to the bathroom more often. He thinks he might have a fever because he has been sweating.

    PMH

    Describes health as good. Has hay fever and psoriasis, medication which was given at last visit worked, not using at this time. No previous back injuries. No daily medications. No herbal medication use. Had his appendix out at age 10.. Previous hospitalization for broken leg requiring traction at age 8. Smokes cigarettes, a pack a day. No ETOH or illicit drug use. Sleeps 5-6 hours a night.NKDA. Immunizations UTD.

    Social

    Married, has four children. Lives with his immediate family and in-laws. Works full time as a plumber. Work has been so busy no time lately for regular exercise.

    Family

    Parents are deceased. Mother died at age 51 from a brain tumor and father died age 53 leukemia. Has one brother in good health.

    Discussion Questions Part One:

    • What further questions do you have for Patrick at this visit?? Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literature or the textbook. List the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests would you order?

    Week 4: Discussion Part Two

    33 unread replies.3434 replies.On further questioning Patrick has no report of further headaches, no fever, or vision changes. No report of nasal congestion, or discharge. No report of wheezing or shortness of breath with rest, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Position changes and Tums did not relieve the pain, he did not try to take any other medication, he did not think he could keep it down if he tried because he is so nauseous.

    Physical exam:

    VS Height: 5 feet 9 inches weight: 198 pounds

    T- 98.9, BP 160/96, P 100, R 22, oxygen saturation: 98%.

    Reports current pain as 8/10. Describes back and stomach pain as throbbing. The pain seems come in waves and at time shoots down into his groin.

    General

    Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Sclera clear, conjunctiva white.

    Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and S2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored.

    Abdomen appears slightly distended, symmetric with no visible masses. RLQ scar noted. Decreased bowel sounds noted. No vascular sounds. Tympany noted in all four quadrants on percussion. Abdomen is soft, no organomegaly, no masses or tenderness. Positive CVAT on right side.

    Urinalysis: Positive WBCs, Small blood. Trace protein, pH 7.0 specific gravity 1.030, negative nitrites, negative ketones, negative glucose

    CBC: WBC 6000 mm3 RBC 5 million Hbg 15g Hct 46% MCV 90 fL MCHC 35 g/dL

    You send Patrick to the in-house ultrasonographer. The report states “a 5mm smooth round calculus is noted at the junction of the ureter and the bladder:

    Discussion Part Two:

    Calculate Patrick’s BMI, does the finding impact his diagnosis or treatment?

    Summarize the history and results of Patrick’s physical exam and then answer the additional case study questions below.

    List the primary diagnosis with ICD10 code. Include your evidence-based rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.

    Answer these additional questions in this post regarding this case:

    What should the NP do if Patrick continues to come back for pain medication?

    What are possible warning signs of prescription drug abuse?

    List three of the twelve 2016 CDC recommendations that would help the provider in handling this case.

     

  • Week 3: Discussion Part One

    11 unread reply.3333 replies.

    Setting: large urban city family practice clinic which employs physicians and nurse practitioners.

    It is Monday here at your clinic. In addition to your regularly scheduled you are being asked to add some additional patients. You note your next visit is a work-in for cough. You review the chart before entering the room to familiarize yourself with this patient’s chart. Katie has been coming to the clinic for years and she and her husband are well known to you but you still review the chart prior to entering the room to assure you are familiar with her history and previous visits. Most of her visits have been for yearly wellness checkups and her labs and vitals are great, even at age 65.

    When you enter the room you see a well-dressed woman looking her stated age sitting on the exam table. Also present is a man who appears to be about 40, the woman introduces him as her son Patrick. Patrick has brought his mother in-law to the clinic today because he is concerned about her cough, it is not getting better. Katie says her son-in-law is worried for nothing but she has had the cough for a bit and it does not seem to be getting better at all.

    HPI

    Katie describes herself as normally really healthy. This cough started a week ago and it is worse at night. The cough wakes her up. Her chest is starting to hurt from all the coughing. She has noticed that she has been more tired and gets easily winded when she takes her daily walks. She has not gone to Curves this week like she usually does because she doesn’t have the energy. She doesn’t think she has fever, did not take her temperature.

    PMH

    Had chicken pox, measles and rubella as a child. Katie has a history of osteopenia, HTN and hyperlipidemia. Takes a daily multivitamin, Evista 60 mg daily and HCTZ 25 mg daily. No reports of past injuries. Previous surgeries include a tonsillectomy and cholecystectomy. Hospitalized for surgeries and childbirth. Has seasonal allergies to pollen and reports hayfever. She is allergic to Demerol, it makes her vomit. No alcohol or tobacco use.

    Social

    Married to John, they live with their married daughter and her family. Takes care of the kids and home as Mary and her husband work. Her husband and son-in-law both smoke, but not in the house.

    Discussion Part One:

    • What further questions do you have for Katie at this visit??
    • Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list with ICD 10 for this visit thus far? Each differential diagnosis should include a one sentence pathophysiology statement supported by the literatureor the textbook.Include the patient’s signs and symptoms and include a rationale statement that explains how the diagnosis is appropriate for your patient.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests would you order?

    Week 3: Discussion Part Two

    11 unread reply.2929 replies.Katie

    Interview information: Upon further questioning about sore muscles, she points to area on right side where she is sore from coughing. It hurts in that spot every time she tries to take a deep breath. No reports of headache, fever, or vision changes. No reports of nasal congestion, or discharge. States she has not been hoarse. No report of wheezing or shortness of breath with rest. No reports of palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion. Tried some cough syrup but that does not stop the cough for long, nothing seems to make it better.

    Physical exam

    VS: Height: 62 inches weight: 140 pounds. T: 100.4, BP 130/90, P 80, R 22, even, oxygen saturation: 96%

    General

    Cooperative, talkative, appropriate. Skin color is pale pink, no cyanosis or pallor. HEENT: Head normocephalic, Hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nares patent without exudate. Oropharynx moist, no lesions or exudate. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small, firm. CARDIOPULMONARY: Heart RRR w/o murmur. Respiratory: Lung sounds are clear left side. Right side: crackles noted on inspiration, did not clear with coughing. On assessment of expansion a slight lag was noted on right side. Tactile fremitus symmetrical. An asymmetrical dullness was noted over right side of back. Abdomen soft, non-tender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted.

    Based on the exam findings you decide to order a chest x-ray (CXR) on Katie.

    While waiting on the CXR results you review her chart more thoroughly. You note she was in for her annual exam one month ago and review her labs. All labs are normal, you note that her CMP results: BUN 19 mg/dl, Creatinine 0.9 mg/dl.

    Her CXR report comes back: The CXR shows a dense shadow in the RLL.

    After you are discuss the X-ray findings with Katie, she asks if you will “take a look” at her son’s elbows. Is there any cream he can put on it?

    Patrick

    States he has itchy, dry flaky skin area on his elbows which started 2 weeks ago.

    Patrick reports he has been picking at skin and it bleeds when he pulls off skin. He states he has been working a lot of overtime, feels really stressed and tired. He has been having tension headaches, taking NSAIDS almost daily for about 3 weeks. The ibuprofen seems to help the headaches a little He has used wife’s hand lotion on the dry skin but did not seem to make a difference. No new foods, soaps or detergents.

    Additional interview responses: No reports of vision changes, ear pan, nasal discharge or sore throat. No reports of difficulty breathing, palpitations or heartburn. No history of health problems or join pain. The rash doesn’t really bother him, but his wife things it is unsightly. Has had a rash on elbows like this once before a few years ago but went away on its own. No surgeries. Previous hospitalization for broken leg requiring traction at age 8. No prescription medications. No herbal medication use. No reports of ETOH, tor illicit drug use. Smokes 1-2 packs/day. NKDA. Reports hayfever in the spring and fall. Immunizations are up to date. Works as a plumber. Sleeps 5-6 hours a night. Parents are deceased. Mother at age 51 from a brain tumor and father age 53 leukemia. Has one brother in good health.

    VS

    Height: 5 feet 9 inches weight: 195 pounds T: 98.4, BP 130/78, P 76, R 20 Sao2 98%.

    Focused exam

    Alert, oriented and cooperative Eyes without exudate, sclera clear, PERRLA. Nares patent without exudate Heart RRR w/o murmur. Lung sounds are clear bilaterally. Tympanic membranes gray and intact with light reflex noted Skin: well-circumscribed deep red, scaling oval plaques noted to bilaterally elbows R>L. Scale is silvery white. No lesions noted on rest of body.

    Discussion Part Two

    Summarize the history and results of the physical exam for each patient in a separate SOAP note for each case study patient.

    Calculate the BMI for each patient.

    List the primary diagnosis with ICD 10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an in-text citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.

    NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code

    Setting

    Large urban city family practice clinic which employs physicians and nurse practitioners.

    Today is another busy in your family practice clinic. You note your next visit is a work in for ear pain. The patients are a set of four year old twins. The entire family has been coming to the clinic for years which is probably why they were worked in despite your full schedule. You review the chart before entering the room to familiarize yourself with these patients.

    When you enter the room you note a Caucasian woman who appears to be about 40 years old. She is well groomed and appropriately dressed for the weather. There are also two boys who appear to be about 4 years old who are sitting on the exam table playing games on their tablets and chatting to each other.

    You introduce yourself as you always do and ask what brings them to the clinic today.

    The mother states “Tommy woke up in the middle of the night saying his ear hurt so badly it woke him up. He says it hurts to touch. Paddy has had a cold for a few and been talking about his ears popping and feeling stuffy. I thought it was just the cold. He woke up this morning and said his ear really hurts too. He also feels warm to me”

    HPI

    Mom describes the boys as overall healthy and active 4-year-old children. Their older sister just got over a cold. The rest of the family has been well but Mom noticed she has a sore throat this morning and asks if you can look at her too as long as they are here. Her throat has hurt since yesterday, and hurts worse when she swallows. She has not eaten or drank anything because it hurts too much.

    PMH

    Paddy: age 4. Full-term pregnancy, NSVD twin gestation 5 pounds 2 ounces. No hospitalizations. NKDA. Daily medication – chewable children’s multivitamin with iron.

    Tommy: age 4. Full-term pregnancy, NSVD twin gestation 5 pounds 4 ounces. No hospitalizations. NKDA. Daily medication – chewable children’s multivitamin with iron.

    Mary (mom): denied past illness or injuries. Hospitalized x 2 for childbirth, no surgeries. NKDA. Drinks alcohol socially, denies tobacco or illicit drug use. Sleeps 6-7 hours/night. No current medications. Takes a daily multivitamin and a B complex vitamin.

    Social

    Paddy and Tommy live with both their parents, Mary and Patrick, and two older siblings. They are in a half day K4 program and Mom states they are doing well and like going to school. Mary’s parents also live with the family and care for the children after school. They have 2 dogs and a cat. Patrick and Mary’s father John Foley both smoke, but not in the house.

    Discussion Part One (Please answer the questions separately for each patient)

    • What further questions do you have forMary at this visit?
    • Use OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list for this visit thus far with rationale? Each differential diagnosis should include a one sentence pathophysiology statement supported by the scholarly literature or the textbook. Link the patient’s presenting symptoms with your differential diagnoses along with rationale.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
    • What further questions do you have forPaddy at this visit??
    • Use your OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list for this visit thus far with rationale?
    • Each differential diagnosis should include a one sentence pathophysiology statement supported by the scholarly literature or the textbook. Link the patient’s presenting symptoms with your differential diagnoses along with rationale.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?
    • What further questions do you have forTommy at this visit??
    • Use your OLDCARTS to guide your questions. Link the questions to your differential diagnoses.
    • What is your differential diagnosis list for this visit thus far with rationale? Each differential diagnosis should include a one sentence pathophysiology statement supported by the scholarly literature or the textbook. Link the patient’s presenting symptoms with your differential diagnoses along with rationale.
    • Based on your differential diagnoses list, what focused PE would you perform? What labs or diagnostic tests, if any, would you order?

    NR 511 Week 6 Part 2 Discussion – SOAP note & ICD 10 code

     

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